Although many hospitals are making strides to reduce the holding of admitted patients in the emergency department, a practice known as “boarding,” many of the most crowded emergency departments in the United States still have not adopted effective interventions, according to a study published yesterday in Health Affairs (“The Most Crowded U.S. Hospital Emergency Departments Did Not Adopt Effective Interventions to Improve Flow, 2007-2010”). A related study published online last week in Annals of Emergency Medicine finds that patients who are boarded in the ER for more than 6 hours are less likely to have their orders completed on time and more likely to have those orders missed entirely (“The Effect of Emergency Department Boarding on Order Completion”).
“There is a broad literature that shows that ER crowding and boarding harm patients,” said Health Affairs study co-author Jesse Pines, MD, FACEP, a professor of emergency medicine at the George Washington University School of Medicine and Health Sciences in Washington D.C. “In the past several years, many hospitals have developed highly effective interventions to help reduce emergency department boarding and crowding, yet many of the most crowded ERs have not prioritized or fixed this problem. From 2007 to 2010, the average number of crowding interventions used by hospitals increased 25 percent, but a serious gap remains for some of the most crowded hospitals. This should be a wake-up call to policymakers and patients that despite having many potential tools to use to address crowding, many hospitals have chosen not to do so.”
The number of hospitals using the full-capacity protocol (moving admitted patients out of the emergency department and onto in-patient hallways) more than doubled between 2005 and 2010, but still is not used at more than 50 percent of all hospitals. In the most crowded quartile of hospital emergency departments, 94 percent still had not adopted surgical smoothing (scheduling surgeries more evenly throughout the week to allow more flexibility to accept patients requiring emergency surgery).
The study in Annals of Emergency Medicine found that 39 percent of orders were completed on time for boarded patients (v. 59 percent in the control group), 21 percent of boarded patients’ orders were delayed (v. 17 percent in the control group) and 39 percent of boarded patients’ orders were missed entirely (v. 22 percent in the control group).
“There is a significant difference in the process of care for admitted patients who board in the emergency department compared to those who are transferred promptly to an inpatient care area,” said lead study author Clinton Coil, MD, MPH of Harbor-UCLA Medical Center in Torrance, Calif. “Boarding degrades the care that emergency patients receive, despite the truly heroic efforts of emergency nurses who struggle to provide inpatient care in emergency departments that were not designed for this purpose. Inpatient wards are designed to provide ongoing care, which is why admitted patients belong there and not in the emergency department.”
About Annals of Emergency Medicine: Annals of Emergency Medicine is the peer-reviewed scientific journal for the American College of Emergency Physicians, the national medical society representing emergency medicine. ACEP is committed to advancing emergency care through continuing education, research, and public education. Headquartered in Dallas, Texas, ACEP has 53 chapters representing each state, as well as Puerto Rico and the District of Columbia. A Government Services Chapter represents emergency physicians employed by military branches and other government agencies. For more information, visit www.acep.org.